Hindawi Publishing CorporationEpilepsy Research and TreatmentVolume 2012, Article ID 273175, 7 pagesdoi:10.1155/2012/273175

Clinical Study

A Seizure Care Pathway in the Emergency Department:Preliminary Quality and Safety Improvements

Parameswaran M. Iyer,1 Patricia H. McNamara,1 Margaret Fitzgerald,1 Liam Smyth,2

Christopher Dardis,2 Tania Jawad,1 Patrick K. Plunkett,2, 3 and Colin P. Doherty1, 2

1 Department of Neurology, St James’s Hospital, Dublin 8, Ireland2 School of Medicine, Trinity College Dublin, The University of Dublin, Dublin 2, Ireland3 Department of Emergency Medicine, St James’s Hospital, Dublin 8, Ireland

Correspondence should be addressed to Colin P. Doherty, cpdoherty@stjames.ie

Received 1 December 2011; Accepted 23 January 2012

Academic Editor: Martin J. Brodie

Copyright © 2012 Parameswaran M. Iyer et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Aim. To evaluate the utility of a seizure care pathway for seizure presentations to the emergency department (ED) in order tosafely avoid unnecessary admission and to provide early diagnostic and therapeutic guidance and minimize length of stay in thoseadmitted. Methods. 3 studies were conducted, 2 baseline audits and a 12-month intervention study and prospective data wascollected over a 12-month period (Nov 2008-09). Results. Use of the Pathway resulted in a reduction in the number of epilepsyrelated admissions from 341 in 2004 to 276 in 2009 (P = 0.0006); a reduction in the median length of stay of those admittedfrom4-5 days in the baseline audits to 2 days in the intervention study (P ≤ 0.001); an improvement in time to diagnostic investigationssuch as CT brain, MRI brain and Electroencephalography (P ≤ 0.001, P ≤ 0.048, P ≤ 0.001); a reduction in readmission ratesfrom 45.1% to 8.9% (P ≤ 0.001); and an improvement in follow-up times from a median of 16 weeks to 5 weeks (P < 0.001).From a safety perspective there were no deaths in the early discharged group after 12 months follow-up. Conclusion. The burdenof seizure related admissions through the ED can be improved in a safe and effective manner by the provision of a seizure carepathway.

1. Introduction

Epilepsy is the most common serious neurological disorderof young people affecting nearly 3.4 million individuals inEurope [1]. Societal costs are considerable as individuals withmedically intractable seizures make up a third of the epilepsypopulation [1]. More than EU15 billion is spent annuallyon the treatment of epilepsy in Europe, a financial burdencomparable to that of lung and breast cancer combined[2, 3]. A Recent Irish prevalence study estimated that upto 40,000 children and adults in Ireland have the disorder,which gives a point prevalence of about 0.9%; in line withother industrialized nations [4]. Studies in the last decadehave shown that the majority of patients with epilepsy will beurgently admitted to secondary and tertiary care institutions(mostly through the ED) at some point in the history of

their illness and a significant proportion will require multiplevisits [2]. Furthermore, symptomatic seizures, secondary toacute medical or surgical illness, alcohol and drug intoxica-tion, brain trauma and stroke, add to the burden of seizurepathology in the ED. Finally, a range of mimic disordersfrom psychogenic nonepileptic seizures (PNES) to blackoutscaused by impaired vascular responsiveness contribute to thediagnostic and therapeutic challenges.

Despite the heavy burden of seizures in the ED, inter-national studies suggest that the majority of patients arereferred unnecessarily for admission and that the acute treat-ment of seizures is often ineffective indicating that seizureadmissions are a cause of unnecessary medical intervention,delayed diagnosis, and prolonged length of stay [5, 6].

Beginning in 2006 we first sought to determine theimpact of emergency seizure admissions on the resources of

2 Epilepsy Research and Treatment

a large Irish teaching hospital. On the basis of two baselineaudits we identified a number of areas where we couldimprove the quality of service to patients with seizures by theemployment of an evidence-based seizure care pathway inthe emergency department (ED) and acute medical admis-sions unit (AMAU). This is a report of preliminary qualityand safety metrics accrued by this intervention over a 12-month period (November 2008-2009).

2. Methods

The study consisted of three parts:

(1) Retrospective audit of admissions with seizuresthrough the emergency department in 2004.

(2) Prospective audit of admissions with seizures throughthe emergency department in August 2006.

(3) Measurement of quality and safety metrics after theimplementation of an evidence-based seizure carepathway from November 2008 to November 2009.

2.1. Part 1: Retrospective Audit 2004. The first study groupwas restricted to in-patients discharged in 2004 with adiagnosis of a seizure or convulsion. These patients wereidentified through the Hospital In-Patient Enquiry (HIPE)system (a national coding system for hospital discharges inIreland), [7] which identified 341 patients with epilepsy orseizure as the primary reason for admission. We completeddetailed retrospective evaluation of the medical records of 50randomly chosen patients. Particular attention was paid toinvestigations, diagnosis, specialist referral, and follow-up.The charts were also examined for what we designated as“Necessity of Admission.” An admission was deemed med-ically necessary if there was a history of prolonged (>5 min-utes) or clustered (>2) events, a history of status epilepticus(>30 minutes of seizure activity), or an abnormal neurologi-cal exam 90 minutes after arrival to the ED. HIPE system wasused to determine if any of these patients was readmitted ordied over a one-year period following admission.

2.2. Part 2: Prospective Audit August 2006. The second studygroup represented all patients who attended the ED with anevent that was deemed likely to have been a seizure or itsaftermath over one calendar month in 2006. A total of 102patients were considered eligible for inclusion. Patients whopresented with a complaint of seizure, weakness, confusion,head injury, dizziness, and collapse of unknown cause wereexamined for possible inclusion in the study. In a similar veinto part 1 of the study, attention was paid to investigations,diagnosis, referral, and follow-up in all patients.

2.3. Part 3: Intervention Study November 2008-2009. Afterthe baseline audits, a seizure care pathway was designed andimplemented by the neurology service with the cooperationof the ED staff. The pathway required early rapid accessambulatory follow-up for patients fit for discharge from theED. A rapid access clinic (RAC) was established and run byan existing epilepsy nurse specialist (ENS). In addition to

patients discharged from wards and the ED, this clinicalso reviewed new referrals from GPs and patients with anestablished diagnosis of epilepsy who had exacerbations oftheir illness, all of which were designed to avoid ED referrals.Education sessions were provided by the ENS who alsoprovided a phone help-line and e-mail service to facilitatefollow-up care. The clinic was overseen by a neurologist.Patients presenting to the ED or admitted to the AMAUovernight with seizures were seen by the seizure servicefellow. Referrals were made through an Electronic PatientRecord (EPR) consultation system.

Patients were managed according to a locally designed,evidence-based, Seizure Care Pathway (Figure 1). The path-way clearly laid out the criteria for:

(1) Admission, discharge and follow-up.

(2) Emergency treatment in the ED or AMAU.

(3) A decision analysis for diagnostic tests.

(4) Referral process for Nurse specialist education andself-management strategies.

The pathway was designed with reference to publishedinternational guidelines of care (Scottish IntercollegiateGuideline Network (SIGN) 2003 (8) and National Instituteof Clinical Excellence (NICE) 2005 (9)). All patients seen bythe seizure service were provided with printed cards with fulldetails for phone and e-mail contact.

2.4. Statistical Analysis. Statistical analysis was carried outon SPSS Version 18 (SPSS Inc., Chicago, IL). Length of stayand time to CT, MRI and EEG were analysed using KruskalWallis test for nonparametric data. The rate of representationwas analysed using Pearson Chi-square test. Times to follow-up were analysed using the Mann-Whitney U test. Thereduction in admission rates was analysed using Chi-squaretest with Yates correction.

3. Results

3.1. Results of Part 1. During 2004, HIPE data identified 341admissions with a specific diagnosis of epilepsy or seizure outof a total of 11,721 admissions from all causes through theED. The median length of stay was 4 days.

In the 50 charts randomly selected out of this group,34% of patients had a previously documented diagnosis ofepilepsy at presentation. Investigations performed includedCT brain (84%), MRI brain (28%), and EEG (56%). Mediandelay to CT, MRI, and EEG were 2 days, 5 days, and 5days, respectively. Ambulatory follow-up was evenly dividedbetween Neurology (28%), General Medicine (28%), andGeneral Practitioner (20%), with a further 24% having nofollow-up whatsoever. 23/50 patients (46%) represented tothe emergency department with further seizures over thenext 12 months.

Using our criteria for “Necessity of Admission,” we con-cluded that 36% could have been discharged earlier or fromthe ED, had appropriate investigations and neurologicalopinion been available in a timely manner. Of the 341

Epilepsy Research and Treatment 3

Seizure care pathway

Seizure

General practitioner

Emergencydepartment

No

Yes Yes

• Nonconvulsive seizure• Single self-limiting convulsion• Awake and alert 90 mins

• Normal neurological examafter seizure

Nonconvulsive seizureSingle self-limiting convulsionAwake and alert 90 minsafter seizureNormal neurological examAnd or normal or unchangedCT/MRI

ADMIT to hospital

Rapid access clinics/nurse-led education clinic/subspecialtyepilepsy clinic/e-mail and phone support

epilepticus or acutetreatment protocol

∗∗Decision analysis forOPD investigations

∗NICE guideline (2005) treatment of status epilepticus and buccal midazolam guideline (page 2)∗∗Decision analysis on investigations EEG/ECG/CT/MRI/LP (page 3)

∗Consider status

Electronic/fax or phonereferral to rapid access clinic

(numbers provided)

Electronic/fax or phonereferral to rapid access clinic

(numbers provided)

Suitable for earlydischarge?

Figure 1: The Seizure Care Pathway used in the Intervention Study from November 2008.

patients with a diagnosis of epilepsy, 10 died over the sub-sequent year but only one of those who presented with statusepilepticus died as a direct result of their epilepsy.

3.2. Results of Part 2. 20 (19%) of the 102 patients included inthe study had a previously established diagnosis of epilepsy.34 (33%) patients were admitted though the ED. Medianlength of stay of those admitted was 5 days. Of the specialinvestigations required for epilepsy, CT Brain was the onlyone conducted on the day of admission and in only 5.8% ofcases. Neither MRI nor EEG’s were performed on any patienton the day of presentation. Ultimately of the 34 admitted,14 (41%) had an EEG, 21 (61%) patients had a CT brain,and 4 (12%) had an MRI Brain. Median delay for EEG was2 days; CT brain was 1 day, and MRI was 2.5 days. No datawas collected on mortality or follow-up as it was designedprimarily to gather data on patients presenting to the ED.

3.3. Results of Part 3. During 2009, there were 276 admis-sions with a primary diagnosis of epilepsy out of 12, 607admissions from all causes through the ED. 350 patients whopresented to ED between November 2008 and November2009 with seizures and other forms of collapse were referredto the seizure team for assessment and had the seizure carepathway applied. 97 patients had an established history ofeither generalised or focal epilepsy and 72 patients hadepilepsy associated with significant medical and surgicalcomorbidities. 34 patients were referred with undefinedcollapse, 12 patients were referred with confusion, and4 patients with myoclonic jerks. Collapses, nonepilepticseizures and confusion accounted for 57 referrals (16.2%).Table 1 shows the complete list of admitting diagnoses.

111 (31%) patients were discharged directly from the ED.30 (8.5%) patients stayed more than 30 days. The medianlength of stay was 2 days.

4 Epilepsy Research and Treatment

Table 1: List of admitting diagnosis.

Underlying diagnosis of study cohort Numbers

Preexisting diagnosis of primary generalised epilepsy 37

Preexisting diagnosis of localisation related epilepsy 60

Generalised status epilepticus 7

Nonepileptic seizures 11

Collapses 34

Antiepileptic medication-related toxicity 3

Significant past medical history of head injury 6

Known primary CNS tumours 8

Known CNS metastasis 6

History of stroke/TIA 8

Stroke presenting as seizures 2

Known history of learning disability 5

Dementia 5

HIV positive 2

Hepatitis B/C positive 10

Schizophrenia 1

Hyponatraemia 11

Sepsis with symptomatic seizure 1

Sepsis with rigors misidentified and referred as seizure 3

Post-operative seizures 3

Seizure after significant physical trauma 1

Of the 181 EEGs requested during the intervention studyperiod, 99 (55%) were done on the same day. 66 (36%)were done within 1 to 3 days, and 16 (9%) were done asoutpatients within 4 weeks. The median delay for EEG in theintervention study was zero days. 150 patients had CT Brainrequested and 140 (93%) were performed on the same dayand median delay for CT brain was again zero days. In 2008-2009, 68 (19%) of the total cohort of 350, had MR imaging ofthe brain requested. Same day MR brain acquisition howeverwent up from 0% in 2004 to 7.2% in 2008-2009 and another8.8% cases were done within 1 to 3 days. The median delayfor MRI brain was 8 days in 2008-2009. Of the 57 patientswith nonepileptic collapse, 12 had an EEG, 18 patients hadCT brain and only one patient had an MRI brain performed.

216/350 patients (61.7%) were seen in follow-up clinics.110 patients (31.4%) were seen in the Rapid Access Clinic(RAC). The median follow-up time to review in the RACwas 4 weeks. 64 patients (18%) were seen in the subspecialtyepilepsy clinic and median follow-up time for this morestable group was 8 weeks. 18 patients (5.1%) were followedup by other services. 6 patients (1.71%) were followed upin other hospitals 31 (8.9%) of the total study group werereadmitted in the 12-month follow-up period.

Of the patients seen during the study period, 19 (5.4%)patients died during the subsequent 12-month follow-up.Only 5 of those died from neurological causes. The remain-der died of a combination of respiratory, cardiac, and onco-logical causes. The neurological causes of death were her-pes encephalitis, obstructive hydrocephalus, nonconvulsivestatus epilepticus and subdural haematoma. Three patients

6

5

4

3

2

1

02004 2006 2008-2009

Median LOS in days

Figure 2: Median length of stay is shown in days for each of thestudy periods in Figure 2.

died of direct seizure-related causes, two with nonconvulsivestatus epilepticus, and one with convulsive status epilepticus.During the intervention study period no patient who wasdischarged from the ED or within 2 days of admission died.

4. Comparisons of Outcomes Across All 3Studies

4.1. Admission Rates. The number of admissions with epi-lepsy or seizure dropped significantly from 341 out of 11,721(2.9%) in 2004 to 276 out of 12, 607 (2.2%) in 2009 (P =0.0006).

4.2. Median Length of Stay. There was a significant reductionin median length of stay between the first 2 audits and theintervention study (P < 0.001). Figure 2 summarises themedian length of stay over the 3 studies

4.3. Time to Investigations. There was a significant improve-ment in time to diagnostic investigations such as CT brain,MRI brain, and electroencephalography between the firsttwo audits and the intervention study (P ≤ 0.001,P ≤ 0.048,P ≤ 0.001). Figure 3 summarizes the median delay toinvestigations on admitted patients across the three studies.

4.4. Follow-up. There was a significant reduction in follow-up times from a median of 16 weeks to 5 weeks (P < 0.001).Figure 4 shows median times to follow-up in the baselineaudit in 2004 and in the intervention study in 2008-2009.

4.5. Readmission. There was a significant reduction in read-mission rates from 45.1% to 8.9% (P ≤ 0.001). Figure 5shows the change in readmission rates between 2004 and theintervention study in 2008-2009

5. Discussion

The use of care pathways in modern healthcare delivery hasbeen somewhat controversial since the expected gains are notalways forthcoming. For instance a Cochrane review of theimplementation of a care pathway in stroke rehabilitationdid not endorse any benefit to patient care [8]. Nevertheless,given the highly variable care delivered in the ED in relation

Epilepsy Research and Treatment 5

2004

2006

2008-2009

Median delay in days for investigations9876543210

CT brain EEG MRI brain

Figure 3: The median length of time to CT brain, EEG and MRIbrain for each of the study periods.

18

16

14

12

10

8

6

4

2

0

Median follow-up time (weeks)

Median follow-up time (weeks)

2004 2008-2009

Figure 4: The median time to follow-up in weeks for the baselineaudit in 2004 and the intervention study in 2008-2009.

to seizure care, we felt that a care pathway could providemuch needed improvement.

The aim of this study was to demonstrate improvementsin for patients presenting to the ED with seizures and relateddisorders, without compromising safety by the use of anevidence-based seizure care pathway. The main quality indi-cators measured were requirement for admission, medianlength of stay, time to diagnostic tests, specialist follow-up,readmission rates, and mortality.

The main findings of the study are that through the uti-lization of the Seizure Care Pathway the ED and AMAU canreduce unnecessary admissions and safely discharge patientsfor early follow-up, which has a very significant impact onreducing representation rates. Timely decision support hasthe effect of significantly reducing time to diagnostic tests,particularly EEG, and thus reducing median length of stayby up to 3 days. All of these outcomes were significant sta-tistically and support the use of care pathways for patientspresenting to the ED with seizures without any increase inmortality. Below we examine each of these benefits.

400

350

250

300

200

150

100

50

0

Return visits to ED

Total patients

Representations to the ED

2004 2008-2009

Figure 5: The rate of representations of patients with seizures to theEmergency Department in 2004 and during the intervention studyin 2008-2009.

5.1. Hospital Admission and Length of Stay. It has been sug-gested that admission of seizure patients is only warranted inpatients who are at high risk of further events, remain drowsyor comatose following a period in the ED, or in whom theneurological exam reveals signs indicative of an underlyinglesion or treatable infective cause. However, internationalstudies suggest that the majority of patients are referredunnecessarily to the in-house medical or neurological ser-vices for admission [5, 6, 9, 10]. In our original retrospectiveaudit (part 1), using a set of criteria based on the aboveindications for admission, we determined that 36% couldhave avoided admission. The intervention study showed thestability of this figure with 31% of patients actually beingdischarged from the ED and a further 8.5% within 24 hoursof admission.

Comparison of HIPE data between 2004 with that of2009 following implementation of the seizure care pathwayshows a reduction in the number of admissions with aspecific diagnosis of epilepsy from 2.9% (341) of totalhospital admissions to 2.2% (276). This is despite an increasein overall admission rates from ED of 7.56% from 11,721 in2004 to 12,607 in 2009. Had admissions continued at therate of 2.9% with no seizure care pathway in place, it wouldhave resulted in 365 epilepsy-related admissions in 2009,suggesting that 89 epilepsy specific admissions were avoideddue to implementation of the seizure care pathway in 2008 to2009. If we consider the median LOS to be 4 days (withoutthe seizure care pathway being applied) this would haveresulted in 356 bed days saved. Combining this figure withthe 478 bed days saved by an overall median reduction in LOSof 2 days, a total of 834 is the projected bed days saved in one12-month period as a direct result of the implementation ofthe seizure care pathway.

The reduction in median length of stay from 4 days in2004 and 5 days in 2006 to 2 days during the interventionstudy in 2008-2009 was made possible by an emphasis uponearly safe discharge in the pathway with an eye to reduce

6 Epilepsy Research and Treatment

bed occupancy days. Establishment of a separate rapid accessfollow-up clinic made routine and even unscheduled earlyfollow-up possible, which increased the safety and ease ofearly discharge. Reductions in length of stay secondary toimplementation of care pathways have been reported in otherareas of heath care, but not in the case of patients withseizures [11–13].

Of the discharged patients, 91.1% were not readmittedwith epilepsy-related causes. The readmission rates show asignificant drop from 47% to 8.9% between 2004 and 2008-2009. The reasons for such a drop are unclear. It is possiblethat some unobserved bias meant that patients more likelyto return were seen in the 2004 audit. It may be due to acombination of more timely and effective inpatient man-agement including the delivery of inpatient ENS education,the provision of phone and e-mail advice services, the useof rapid access to ambulatory clinics for exacerbations ofexisting epilepsy, and improved, timely communication withprimary care teams. The reduction of median follow-up timefrom 16 weeks during 2004 to 5 weeks in 2008-09 may alsohave helped in reducing re-admissions to the ED.

5.2. Mortality. In relation to the overall safety of the seizureservice with its emphasis on reducing admissions and lengthof stay, we found that only three of the 19 deaths in thestudy group were directly attributable to epilepsy. In 2004,only one death was attributable to epilepsy. While there is aslight increase in epilepsy-related deaths, there was no excessmortality in any patients discharged from the ED or withinthe 2-day median length of stay window.

5.3. Investigations. Accurate diagnosis and classification ofseizure type are essential to the provision of quality patientcare and good control. EEG is described as an important aidin the evaluation of seizure patients [14]. In relation to thebaseline audit the median waiting time to EEG was 5 days,demonstrating that most patients were not being tested soonafter the seizure period. Such waiting times observed in thebaseline audits suggested that EEG contributed significantlyto the length of stay of individual patients. During theintervention study the involvement of early specialist opinionallowed for the streamlining of those who required EEGwhich occurred on the day of admission in approximately54% of the study group and in total over 90% had the testdone in 3 days or less.

Neuroimaging is essential to identify structural lesions,which may result in the development of a seizure disorder.Jackson et al. [15] assert that MRI is the gold standard imag-ing investigation for suspected focal lesions. Despite strongconsensus within the literature for performing MRI over CTespecially in focal seizures [5, 15, 16] CT was the preferredmodality for neuroimaging within all our study groups. Thisis largely to do with the ease of access to CT over MRI atour institution, which has not changed significantly since2004. 84% of the retrospective sample had a CT performed,whilst only 28% had an MRI. In the intervention study only42% of patients had a CT requested reflecting the fact thatin a number of cases of either established epilepsy or indeedEEG proven Primary Generalized Epilepsy, the pathway was

able to obviate the need for CT. An improvement in time tobrain imaging was demonstrated in the intervention studywith 93% of patients having their CT on the same dayof request. Unusually, the mean wait time for MRI brainincreased in 2009 compared to 2004. This, we believe, wasdue to the steadily increasing demand for MRI brain in acutepresentations of seizure over those years coupled with limitedavailability of our MRI resource (one magnet open onlyduring office hours). This has been ameliorated lately by theaddition of a second scanner.

5.4. Review and Follow-up. As outlined by the SIGN [16]and NICE [17] guidelines, adults with epilepsy should have aspecialist expert opinion in an ambulatory setting includingregular structured annual review. In the retrospective 2004audit, mean time to neurology clinic follow-up was 14 weeksand only 28% of patients were followed up by the specialty.The lack of decision support and or expert neurologicalopinion to two-thirds of the 2004 study group may havecontributed to the longer length of stay in this group as theremay have been a delay in diagnosis and pursuing appropriateinvestigations. Only 28% of that group were followed upby the neurology service in outpatient clinics, which wespeculate may have contributed to return ED presentationsand readmission rates. The intervention study suggests thatthe decision support embodied in the Seizure Care Pathwayand early follow-up contributed significantly to a reductionin readmission rates.

6. LimitationsRetrospective chart reviews, which formed the basis ofinitial baseline data, are hazardous for deciding on serviceprovision due to the unreliability and potential bias in thedata. Furthermore, the initial analysis was on a relativelysmall number of charts. In this study we complimented theretrospective audit with a short prospective audit, whichvalidated some of the retrospective audit and independentlyverified characteristics of patients admitted with epilepsy andtheir course in hospital. The intervention study was largeenough to draw conclusions but its comparison to the twoprior audits must be done with caution as the patient char-acteristics may have been biased in the smaller studies. Thiswas exemplified by the significant differences in readmissionrates between the two audits and the intervention study.While some of the difference were undoubtedly due to serviceimprovements, the scale of difference suggested a possiblebias in patient characteristics.

Finally, for system-wide change the decisions that con-tributed to the improved quality metrics would have ideallybeen made by ED and acute medical staff and specialistnurses applying the principles in the seizure care pathway. Inthis study the pathway was implemented by a specialist ser-vice and thus the generalizability of the results in unclear.However, the lack of widespread use of pathways for seizurepresentations requited that a proof of principle study wasrequired. Future study should now focus on the use of anintegrated care pathway (ICP) without resource necessarilyto a specialist at the ED/AMAU interface.

Epilepsy Research and Treatment 7

7. Summary and Recommendations

It appears that a large proportion of seizure-related presen-tations are referred to the in-house medical or neurologicalteams for admission, due in large part to the lack ofaccess to appropriate algorithms for admission and decisionsupport for early treatment and diagnostic investigationand the difficulty in obtaining outpatient investigations andspecialist epilepsy follow-up in a reasonable length of time.This study conducted over a 12 month period using baselinedata collected between 2004 and 2006 shows that using anevidence-based care pathway with early specialist advice andfollow-up, along with directed patients education and arange of communication tools to aid in self-managementsuch as telephone and e-mail advice, can contribute signif-icantly to quality and value improvements in epilepsy carewithout compromising safety. We recommend further studyof this programme and we have embedded a continuousimprovement cycle into prospective audit.

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[1] S. D. Shorvon, The Treatment of Epilepsy, Blackwell, Oxford,UK, 2005.

[2] M. Pugliatti, E. Beghi, L. Forsgren, M. Ekman, and P. Sobocki,“Estimating the cost of epilepsy in Europe: a review witheconomic modeling,” Epilepsia, vol. 48, no. 12, pp. 2224–2233,2007.

[3] P. Andlin-Sobocki, B. Jonsson, H. U. Wittchen, and J. Olesen,“Cost of disorders of the brain in Europe,” European Journal ofNeurology, vol. 12, supplement 1, pp. 1–27, 2005.

[4] C. Linehan, M. P. Kerr, P. N. Walsh et al., “Examining theprevalence of epilepsy and delivery of epilepsy care in Ireland,”Epilepsia, vol. 51, no. 5, pp. 845–852, 2010.

[5] M. J. G. Dunn, D. P. Breen, R. J. Davenport, and A. J. Gray,“Early management of adults with an uncomplicated firstgeneralised seizure,” Emergency Medicine Journal, vol. 22, no.4, pp. 237–242, 2005.

[6] G. D. Cascino, D. Hesdorffer, G. Logroscino, and W. AllenHauser, “Treatment of nonfebrile status epilepticus in Roches-ter, Minn, from 1965 through 1984,” Mayo Clinic Proceedings,vol. 76, no. 1, pp. 39–41, 2001.

[7] Casemix Ireland, HIPE Coding Auditing Toolkit (HCAT)Information Leaflet, Casemix Ireland, 2007.

[8] J. Kwan and P. Sandercock, “In-hospital care pathways forstroke: an updated systematic review,” Stroke, vol. 36, no. 6,pp. 1348–1349, 2005.

[9] J. Ryan, S. Nash, and J. Lyndon, “Epilepsy in the accident andemergency department—developing a code of safe practice foradult patients,” Emergency Medicine Journal, vol. 15, no. 4, pp.237–243, 1998.

[10] H. Bhatt, M. S. Matharu, K. Henderson, and R. Greenwood,“An audit of first seizures presenting to an accident and emer-gency department,” Seizure, vol. 14, no. 1, pp. 58–61, 2005.

[11] S. D. Pearson, S. F. Kleefield, J. R. Soukop, E. F. Cook, andT. H. Lee, “Critical pathways intervention to reduce length ofhospital stay,” American Journal of Medicine, vol. 110, no. 3, pp.175–180, 2001.

[12] J. P. Co, K. B. Johnson, A. K. Duggan, J. F. Casella, and M.Wilson, “Does a clinical pathway improve the quality of carefor sickle cell anemia?” The Joint Commission Journal onQuality and Patient Safety, vol. 29, no. 4, pp. 181–190, 2003.

[13] S. M. Dy, P. Garg, D. Nyberg et al., “Critical pathway effec-tiveness: assessing the impact of patient, hospital care, andpathway characteristics using qualitative comparative analy-sis,” Health Services Research, vol. 40, no. 2, pp. 499–516, 2005.

[14] A. Kawkabani, A. O. Rossetti, and P. A. Despland, “Survey ofmanagement of first-ever seizures in a hospital based commu-nity,” Swiss Medical Weekly, vol. 134, no. 39-40, pp. 586–592,2004.

[15] N. Jackson, N. Delanty, and C. A. Ridge, “Imaging in patientswith a first seizure,” Irish Medical Journal, vol. 99, no. 6, 2006.

[16] Scottish Intercollegiate Guideline Network, “Diagnosis andmanagement of epilepsy in adults,” 2003, http://www.sign.ac.uk/.

[17] National Institute for Clinical Excellence, “The epilepsies:the diagnosis and management of the epilepsies in adults andchildren in primary and secondary care,” 2005, http://www.nice.org.uk/.

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